Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate: A systematic review.

PURPOSE: The purpose of this study is to compare the patient-reported outcomes and return to sports of the conservative and surgical treatment of distal hamstring tendon injuries. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers searched PubMed, Scopus and Virtual Health Library databases in January 2023. Clinical studies evaluating conservative or surgical management outcomes of distal hamstring tendon injuries were considered eligible for this systematic review if predefined criteria were fulfilled: (1) published in English or Spanish; (2) evaluated any of the following: patient-reported outcomes, return-to-sports rate (RTS-R) or return-to-sports time (RTS-T). Data were presented in tables using absolute values from individual studies and derived pooled percentages. RESULTS: Eighteen studies were included for 67 patients and 68 distal hamstring tendon injuries. Initially, 39 patients (58.2%) underwent surgical treatment, whereas 28 (41.8%) were treated conservatively. Among conservative treatment patients, 15 failed and had to be operated on (53.6%), all with distal semitendinosus tendon injuries. Anchor fixation was the technique of choice in 20 lesions (36.4%), tenodesis in 16 (29.1%), tenectomy in 14 (25.5%) and sutures were preferred in five (9%). Thirteen out of 28 patients (46.4%) undergoing initial conservative treatment returned to sports at a mean of 3.6 months (range 1 week to 12 months), in contrast to surgical treatment, in which 36 out of 39 patients (92.3%) returned at a mean of 4.2 months (range 6 weeks to 12 months). Additionally, 14 of 15 patients (93.3%) converted to surgical treatment after failed conservative treatment returned to sports at a mean of 7.6 months after injury. CONCLUSION: Initial surgical treatment of distal hamstring tendon injuries yields a high RTS-R (92.3%) at a mean of 4.2 months. Furthermore, 15 out of 28 patients (53.6%) initially treated conservatively had to be operated on, delaying the RTS-T (mean 7.6 months after injury) without affecting their RTS-R. LEVEL OF EVIDENCE: IV.

Reverse or Ulnar-Sided, Greater Arc Perilunate Injury: Case Report and Systematic Review of Literature.

BACKGROUND: Perilunate injuries of carpal bones are uncommon, high-energy injuries that necessitate early diagnosis and appropriate management to prevent progressive carpal instability and posttraumatic osteoarthritis. A much more uncommon mechanism that starts from the lunotriquetral ligament and proceeds radially in an opposite direction than the classic mechanism may cause a reverse or ulnar-sided perilunate dislocation (PLD). The purposes were: (1) to present an uncommon case of greater arc reverse (ulnar-sided) perilunate fracture-dislocation (REPLFD); and (2) to conduct a systematic review (SR) to evaluate the current evidence on reverse perilunate injuries (REPLIs). METHODS: A novel pattern of injury of REPLFD with fractures of the ulnar styloid, triquetrum, and capitate is presented. A SR was conducted with primary outcome measures of the type of injury (pathoanatomy of lesions) and pathomechanics. Secondary outcome measures were choice of surgery and outcome on follow-up. RESULTS: The Murad's tool and modified Coleman Methodology Score revealed poor methodological quality of the available literature on REPLI. Evidence is lacking in the mechanism of injury and treatment of REPLI, especially regarding REPLFD. CONCLUSIONS: The SR revealed poor methodological quality of the available literature and exposes that not all PLDs can be explained by the current existing pathomechanical injury classifications. However, following the management principles of perilunate injuries, REPLI tends to have good functional results with no major complications. LEVEL OF EVIDENCE: Level V.

Louis Farabeuf (1841-1910): Anatomist and inventor of surgical procedures and instruments.

Louis Hubert Farabeuf (1841-1910) was a reformer of clinical, surgical, and topographic human anatomy studies during the second half of the 19th century. Over 30 years as a professor of Anatomy, Farabeuf wrote outstanding anatomical textbooks. As the head of Anatomic Studies in the Faculty of Medicine in Paris, he succeeded in leading a profound restructuring of the way anatomy and surgery were taught. As a result of his work and research, several anatomical terms, clinical signs, and surgical instruments were named after him. For his outstanding career in anatomy, he was elected to the Academy of Medicine in 1897.

Lacertus syndrome: a ten year analysis of two hundred and seventy five minimally invasive surgical decompressions of median nerve entrapment at the elbow.

PURPOSE: This study aims to assess the clinical presentation and surgical outcomes of lacertus syndrome (LS) and concomitant median nerve entrapments. METHODS: A retrospective study of prospectively collected data was conducted on patients undergoing lacertus release (LR) from June 2012 to June 2021. Available DASH (Disability of the Arm Shoulder Hand questionnaire) scores and post-operative Visual Analogue Scale (VAS) of pain, numbness, subjective satisfaction with surgical outcome, and intra-operative return of strength were analyzed. RESULTS: Two-hundred-seventy-five surgical cases were identified of which 205 cases (74.5%) underwent isolated LR, and 69 cases (25.1%) concomitant lacertus and carpal tunnel release. The three most common presenting symptoms in LS patients were loss of hand strength (95.6%), loss of hand endurance/fatigue (73.3%), and forearm pain (35.4%). Numbness in the median nerve territory of the hand was found in all patients with combined LS and carpal tunnel syndrome. Quick-DASH significantly improved (pre-operative 34.4 (range 2.3-84.1) to post-operative 12.4 (range 0-62.5), p < 0.0001) as did work and activity DASH (p < 0.0001). The postoperative VAS scores were pain VAS 1.9 and numbness VAS 1.8. Eighty-eight percent of patients reported good/excellent satisfaction with the surgical outcome. Intra-operative return of strength was verified in 99.2% of cases. CONCLUSION: LS is a common median nerve compression syndrome typically presenting with loss of hand strength and hand endurance/fatigue. Minimally invasive LR immediately restores hand strength, significantly improves DASH scores, and yields positive outcomes regarding VAS pain, numbness, and subjective satisfaction with surgery in patients with proximal median nerve entrapment at a minimum six month follow-up.

Tibial tubercle fractures are sports injuries in male adolescents with a considerable risk of complications and reoperations: a systematic review.

PURPOSE: There is growing interest in tibial tubercle fractures in pediatric and adolescent population within the last decade. However, there is limited evidence in the existing literature. Therefore, the purpose of this systematic review was to analyze and provide up-to-date data that may prove valuable in decision making and management of these injuries in the general as well as the athletic population. METHODS: A systematic review of the literature in PubMed, Cochrane library and Virtual Health Library was conducted using the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" (PRISMA) guidelines. Articles published in English or Spanish, during the past 20 years, reporting outcomes of tibial tubercle fracture management in patients younger than 18 years old, with a mean follow-up of at least 6 months reporting outcomes, type of management and classification were included. RESULTS: A total of 919 patients with 956 fractures in 25 retrospective cohort studies were included. The mean age was 14.4 ± 0.6 years while 766 [83%] were males and 740 [81%] of the injuries were sports-related. Associated injuries were reported in 91[10%] cases, most common being patellar tendon avulsion. Surgical management was chosen for 845[88%] of the cases, the vast majority being open reduction internal fixation (ORIF) with screws. Union was achieved in 954 [99.8%] cases. Complications and re-operations rate stood at 172[18%] and 161 [19% of the operations], respectively. Return to play (RTP) was reported in 11 [44%] of the studies standing at an average of 98.9% ± 3.6. CONCLUSION: Essentially, this is an adolescent sports knee injury that needs careful planning before decision making because it may affect both RTP and joint preservation. Although union was achieved in almost all patients, there is a high risk of associated injuries, complications and reoperations. The surgeon should be confident to perform fracture fixation as well as addressing associated knee soft tissue injuries to achieve optimal outcomes. LEVEL OF EVIDENCE: Level IV.

Tibial Nerve Palsy: An Atypical Presentation of a Popliteal Cyst.

Popliteal cysts represent one of the commonest knee pathologies in the adult population. The vast majority of cases may be treated conservatively as symptoms tend to resolve spontaneously. However, few patients may experience persistent pain and nerve-related symptoms not responding to conservative management. We present a case of a 46-year-old patient who suffered from tibial nerve palsy due to a popliteal cyst that was treated successfully with combined open and arthroscopic procedure. It is important to understand that popliteal cysts rarely may lead to tibial nerve entrapment and in selected cases operative management may be indicated.

Reduplicated medial parapatellar plica: a case of a medial plica anatomical variation recalcitrant to conservative treatment.

PURPOSE: The current study aims to report the radiologic and clinical appearance of a rare anatomical variation of the knee medial synovial plica along with its response to conservative and surgical treatment. CASE PRESENTATION: This report portrays a 29-year-old male patient with anteromedial gradual onset right knee pain, aggravated when descending stairs or prolonged sitting. Physical examination revealed medial parapatellar local tenderness, a palpable click in this area when the knee was extended, and hamstring tightness. Magnetic resonance imaging showed a duplicated medial plica, characterized by a high-intensity signal of the infrapatellar fat pad medial portion, after which a presumptive diagnosis of medial plica syndrome was proposed. After conservative treatment failure, the patient underwent standard knee arthroscopy that revealed a superior low profile and an inferior high profile medial plica, and hypertrophy of the medial portion of the infrapatellar fat pad. Both plicae and fat pad were resected with a mechanical shaver until no contact between the femoral trochlea and the fat pad was observed during full range of motion. At 4 weeks postoperatively, symptoms completely resolved, and the patient was allowed to return to full activity with no recurrences at 1 year follow-up. CONCLUSIONS: The current study presented a rare anatomical variation of the knee medial synovial plica that was symptomatic and recalcitrant to conservative treatment. This case report may be useful for radiologists and orthopaedic surgeons to differentiate this special plica type and consider its response to conservative and surgical treatment during patient management.

Endoscopic curettage and allografting of simple bone cysts of the calcaneus in young soccer players: Report of three cases.

Open curettage with bone graft has been the traditionally suggested surgical treatment for the symptomatic simple (or unicameral as they used to be called) calcaneal bone cyst. Less invasive endoscopically assisted treatment with curettage and bone grafting with allograft have recently provided less postoperative morbidity. The aim of the present study is to present our experience with this method in young soccer athletes. Between April 2014 and May 2016 three consecutive young soccer players with symptomatic calcaneal bone cysts underwent endoscopic curettage, and percutaneous injection of demineralized bone matrix allograft. The mean age was 17.3 (16, 17 and 19 years old), and the mean follow-up was 32.1 (range 24-47) months. Both radiographic and functional follow-up, using the AOFAS score, showed good to excellent results. All lesions were radiographically healed. Preoperative AOFAS score (max. 100 pts) was 78.6 ± 4.7, improving to 98.0 ± 4.1. The patients returned to their initial level of sports activities within 18.3 (range 17-19) weeks after surgery. Evidence suggests an earlier return to sports using bone substitutes. However, the present study showed that endoscopic curettage and percutaneous injection of bone allograft is also an excellent treatment option for young athletes with a symptomatic calcaneal bone cyst. LEVEL OF CLINICAL EVIDENCE: 4.

Surgical management of upper limb lipoma arborescens: a systematic review.

BACKGROUND: Lipoma arborescens (LA) is a rare benign synovial tumour characterized by the proliferation of mature adipocytes within the synovial cells. Given its rarity, current evidence is mainly based on case reports and case series, and no guidelines are available. The present study investigated the current surgical management and related outcomes of LA in the upper limb. METHODS: This systematic review was conducted following the PRISMA guidelines. PubMed, Scopus, and Virtual Health Library were accessed in September 2021. Clinical studies evaluating patients with LA undergoing surgical treatment were considered eligible for this systematic review. Only studies which reported data on LA located in the upper limb with histopathological confirmation were considered. Articles that reported data from nonsurgical management were not considered. RESULTS: A total of 21 studies reporting 22 lesions in 21 patients were assessed. The mean age of the patients was 48.48 years (range 22-77). Most studies evaluated the restoration of range of motion and symptom resolution for the functional outcome assessment. Open or arthroscopic excision and synovectomy were the most common surgical procedures for LA. The concomitant lesions were treated in a single-stage procedure. All patients had satisfactory outcomes after open or arthroscopic excision and synovectomy without recurrence at a mean follow-up of 21.14 months (range 2-60). One patient developed postoperative cellulitis (4.55%). CONCLUSION: Open and arthroscopic excision combined with synovectomy should be considered the standard treatment option of upper limb LA. Concomitant pathologies can be addressed in a one-stage procedure. Although LA was recognized as a clinical entity decades ago, there is a lack of evidence based guidelines and long term outcome data are unavailable.

Hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective.

PURPOSE: This systematic review evaluated the clinical outcomes of hardware-free MPFL reconstruction techniques in patients with recurrent patellofemoral instability, focusing on patient-reported outcome measures (PROMs), redislocation rate, and complications. The hypothesis was that hardware-free MPFL reconstruction in patients with recurrent patellofemoral instability is safe and effective. METHODS: This systematic review was conducted following the PRISMA guidelines. PubMed, Scopus, and Virtual Health Library databases were accessed in October 2021. All the clinical studies investigating the efficacy and feasibility of hardware-free MPFL reconstruction were screened for inclusion. Only studies with a minimum 24-month follow-up were considered eligible. Kujala Anterior Knee Pain Scale improvement and redislocation rate after surgical treatment were evaluated as primary outcomes. The rate of postoperative complications was evaluated as a secondary outcome. The quality of the methodological assessment was assessed using the Modified Coleman Methodology Score. RESULTS: Eight studies were included in the present systematic review. The quality of the methodological assessment was moderate. Short- to long-term improvement of Kujala score was observed in all included studies. Mean score improvement ranged from + 13.2/100 to + 54/100, with mean postoperative scores ranging from 82/100 to 94/100. Patellar redislocation was observed in 8.33% (8 of 96) patients. CONCLUSION: Hardware-free MPFL reconstruction with or without associated soft-tissue or bony realignment procedures provided reliable clinical improvements and was associated with a low rate of redislocation in patients with recurrent patellofemoral instability. Advantages such as safety, femoral physis preservation, and comparable complication profiles with implant-based techniques endorse its implementation. Orthopedic surgeons in cost-sensitive environments may also benefit their patients with lower costs, no need for implants, lack of implant-related complications, or surgery for implant removal. LEVEL OF EVIDENCE: Level IV.

Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review.

BACKGROUND: To determine the incidence of concomitant intra-articular glenohumeral injuries in patients undergoing surgical management from distal clavicle fractures (DCF) with shoulder arthroscopy and their impact on outcome. METHODS: This systematic review was conducted following the PRISMA guidelines. PubMed, EMBASE, and Virtual Health Library databases were accessed in October 2021. All the clinical studies evaluating the surgical management of DCF and using concomitant intra-operatory shoulder arthroscopy were included. Studies that did not specify the concomitant injury type were not eligible. Data from the incidence of intra-articular glenohumeral injuries, injury type, length of the follow-up, and clinical outcomes were retrieved. The quantitative content assessment was performed using the STROBE statement checklist. Evaluation of the publication bias of the included studies was performed using the risk of bias assessment tool for systematic reviews. RESULTS: Data from five retrospective and five prospective cohort studies were analyzed. Eight of the included studies were conducted on patient cohorts with Neer type II injuries. Data pooling revealed a mean of 17.70% of concomitant glenohumeral injuries, whereas 84.21% of them required additional surgical management (Table 1). Rotator cuff injuries, labral tears, and biceps pulley lesions were the most common concomitant injuries. CONCLUSION: Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to DCF should be recommended.

Arthroscopic debridement of osteochondral lesions of the talus: A systematic review.

BACKGROUND: Arthroscopic debridement (AD) for the osteochondral lesions of the talar dome (OLT) was widely documented in the nineties with satisfactory results. However, in modern treatment algorithms, its role is not described. The present systematic review aims to evaluate the current evidence on the clinical outcomes of AD in the management of OLT. METHODS: Two independent reviewers searched PubMed, EMBASE, Scopus, and Virtual Health Library databases evaluating the clinical outcomes of AD of OLT with a minimum 6-month follow-up. The following terms "talus", "chondral", "cartilage", "injury", "lesion", "delamination", "damage", "excision", "curettage", "debridement", "chondrectomy", "chondroplasty", were used alone and in combination with Boolean operators AND and OR. Studies in which surgical technique was not described, an additional procedure was performed after debridement, and/or outcomes were not reported separately when more than one technique was implemented were excluded. The modified Coleman methodology score (mCMS) was used to evaluate the methodological quality of the included studies. A narrative analysis was conducted. Publication bias was assessed using the ROBIS tool. RESULTS: AD showed satisfactory short and medium-term outcomes for the primary treatment of OLT irrespectively of size and depth. However, the heterogeneity of the included studies and the level of available evidence hinders its recommendation. CONCLUSIONS: There is a paucity of evidence evaluating AD alone for OLT treatment in the last two decades. Bone-marrow stimulation techniques remain the first-line surgical strategy for OLT treatment without proven superiority. Adopting AD for OLT treatment instead of MF could represent a paradigm breakthrough in clinical practice given its many potential advantages while preserving the subchondral plate.

Diagnosis and epidemiology of winged scapula in breast cancer patients: A systematic review and meta-analysis.

BACKGROUND: Winged scapula (WS) is a critical complication of axillary surgery in patients treated for breast cancer, and is associated with pain, impairment of the upper extremity's function and poor performance in daily activities. SOURCES OF DATA: A systematic review and meta-analysis were performed following the PRISMA guidelines. Two independent reviewers searched PubMed, Embase and Virtual Health Library databases from January 1, 2000 to December 1, 2020. Clinical studies evaluating the diagnosis and epidemiology of WS among breast cancer surgery (BCS) patients were included. AREAS OF AGREEMENT: The diagnosis of WS relies almost entirely on physical assessment. Studies have suggested a high variability in the report of the incidence of WS given the subjectivity of its diagnosis, and the different criteria used during clinical assessment. AREAS OF CONTROVERSY: The diagnosis of WS in BCS patients remains a challenge given the lack of standardized diagnostic protocols. Physical examination cannot rely on one manoeuvre only, as it may overlook patients with subtle injuries or overweight and contributing to the underreporting of its incidence. GROWING POINTS: BCS patients undergoing axillary lymph node dissection experience a significantly higher incidence of WS than those undergoing sentinel lymph node dissection. The global incidence of WS after BCS is 16.79%. Additionally, the anterior flexion test and the push-up test are the most commonly performed diagnostic manoeuvers. AREAS TIMELY FOR DEVELOPING RESEARCH: Further studies should aim for objective diagnostic tests, especially when the condition is not evident.

Minor Shoulder Injury Reveals Spontaneous Regression of Proximal Humerus Osteochondroma.

Osteochondromas are the most common benign bone tumor; nonetheless, the natural history is poorly understood as a result of the low threshold for resection and the fact that many of these lesions are asymptomatic and therefore never diagnosed. We present a case of a 17-year-old patient whose routine shoulder X-ray evaluation, due to a minor shoulder injury, revealed spontaneous regression of a previously documented left proximal humerus osteochondroma at six years follow-up. The likelihood of spontaneous regression should be better understood by orthopedic surgeons and taken into account in the decision process of whether to remove osteochondromas surgically or wait.

Inverted deltoid posterior cruciate ligament femoral insertion accompanied with medial synovial fold: a case of a complex posterior cruciate ligament anatomical variation recalcitrant to conservative treatment.

PURPOSE: The present study aims to report a symptomatic rare anatomical variation of the posterior cruciate ligament (PCL) that was encountered during arthroscopy. CASE PRESENTATION: A 34-year-old female suffered from dull anterior pain in the right knee, along with stiffness and the presence of an audible click and occasionally locking during deep knee flexion. Physical examination revealed only slight pain during single-leg squatting and mild knee effusion with painful limitation of the last degrees of flexion. Following unsuccessful conservative treatment, knee arthroscopy was performed in which the PCL was found to be hypertrophic, having a broad femoral insertion that almost completely occupied the intercondylar notch and impinged the anterior cruciate ligament. Moreover, the PCL presented a large medial synovial fold that formed a plica inserting to the medial meniscus's posterior horn. Ligamentoplasty was performed by excising one-third of the PCL lateral portion. The PCL medial synovial fold and the plica attaching to the medial meniscus were resected. The patient was allowed to return to full activity when her symptoms resolved, and the knee function was restored, at 5 weeks post-operatively. CONCLUSION: The current study presented a rare and complex anatomical variation of the PCL that was symptomatic and recalcitrant to conservative treatment. Magnetic resonance imaging (MRI) can reveal the variant morphology of the PCL, and arthroscopy provides the definite treatment. This case report may be useful for orthopaedic surgeons and radiologists to consider anatomical PCL variations during differential diagnosis in patients with non-specific clinical presentation and findings.

Arthroscopic os trigonum en-bloc removal outcomes at 6-month follow-up are better compared to Stieda's process resection in patients with posterior ankle impingement syndrome: a prospective comparative study.

OBJECTIVE: To evaluate the potential differences in American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Foot Function Index (FFI) at 6-month and 12-month postoperative follow-up of arthroscopic treatment for posterior ankle impingement (PAIS) between os trigonum (OT) and Stieda's process (SP) patients. METHODS: Thirty consecutive patients (32 ankles) treated in our Institution for PAIS with posterior arthroscopy were prospectively enrolled in the study from December 2012 to July 2019. Indications were patients with PAIS with persistent symptoms following conservative management. Exclusion criteria were the coexistence of concomitant pathologies and patients who underwent additional surgical procedures. An independent investigator interviewed and evaluated the patients according to the AOFAS hindfoot score and FFI preoperatively, at 6-month and 12-month follow-up. RESULTS: Except for AOFAS scores in the SP group (MD (mean difference) 11.28, p=0.08), patients undergoing arthroscopic treatment for bony PAIS had an overall significant improvement in AOFAS score (OT MD 22.29, p<0.05) and FFI (OT MD -70.07, p<0.05; SP MD -50.96, p<0.05) from their preoperative scores at 6-month follow-up. Similarly, a significant improvement in AOFAS score (OT MD 5.78, p=0.01; SP MD 12.14, p<0.05) and FFI (OT MD -9.36, p=0.04; SP MD -26.43, p<0.05) was observed from the 6-month to 12-month follow-up in all groups. At 6-month follow-up, the OT group had significantly better FFI outcomes (MD -33.57, p=0.04) compared with the SP group. No differences were found by group when comparing AOFAS score and FFI score at 12-month follow-up. CONCLUSIONS: When comparing patients undergoing OT excision or SP resection, better FFI outcomes were observed in the OT group at 6-month follow-up. LEVEL OF EVIDENCE: Prospective comparative study. Level II.

Arthroscopic debridement for focal articular cartilage lesions of the knee: A systematic review.

BACKGROUND AND PURPOSE OF THE STUDY: Arthroscopic debridement, the most commonly applied surgical technique for focal cartilage lesions in the knee, is not included in most treatment algorithms because of discouraging results in the management of osteoarthritis of the knee. The present systematic review evaluates the outcome of arthroscopic cartilage debridement as the primary treatment of focal knee chondral lesions in adults, and defines its indications and role as the primary treatment of focal knee chondral lesions. METHODS: Two independent investigators searched PubMed, Cochrane CENTRAL, and Virtual Health Library databases using the terms "knee", "cartilage", "chondral", "lesions", "injury", "damage", "debridement", "chondroplasty", "chondrectomy", alone and in combination. Clinical studies evaluating the effect of mechanical cartilage debridement in adults with symptomatic focal cartilage lesions in the knee joint regardless of the defect size and depth were included. We excluded studies if patients had a concomitant ligament or meniscus injury, and/or had additional debridement with monopolar radiofrequency energy. MAIN FINDINGS: Available studies suggest good to excellent short and medium-term functional outcomes (KOOS, LKSS, Tegner scale) for focal cartilage lesions treated with debridement regardless of the defect size and depth. Data are lacking comparing cartilage debridement versus other cartilage repair techniques. CONCLUSIONS: Arthroscopic debridement of focal articular cartilage lesions of the knee is associated with good to excellent short and medium-term postoperative outcomes, especially in terms of functional improvement. Arthroscopic debridement may be considered in the primary treatment of focal cartilage injuries regardless of the defect size and depth. However, available studies are limited and the level of evidence is low.